past paper questions 6 Flashcards
two main causes of mitral valve stenosis?
- rheumatic heart disease
- infective endocarditis
causes a mid-diastolic, low pitched ‘rumbling’ murmur
mitral stenosis is associated with:
- malar flush
- due to back pressure of blood into pulmonary system
- causing rise in CO2 and vasodilation - atrial fibrillation
- caused by left atrium struggling to push blood through stenotic valve, causing strain, electrical disruption and resulting in fibrillation
mitral regurgiation results in:
- pan-systolic high pitched whistling murmur
- murmur radiates to left axilla
causes:
- Idiopathic weakening of the valve with age
- Ischaemic heart disease
- Infective Endocarditis
- Rheumatic Heart Disease
- Connective tissue disorders such as Ehlers Danlos syndrome or Marfan syndrome
18 y/o female
pc: recurrent episodes of abdominal pain and diarrhoea.
hpc: recently returned from trip to south east asain.
OE: slightly flushed, temp 37.3, 88bpm, blood pressure 104/72.
Palpation of abdomen: mild tenderness in LIF.
Sigmoidoscopy reveals, discrete areas of inflammation in bowel with nodular cobble stone appearance.
indicative of:
Crohns disease
50 y/o undergoes lapaoscopic cholecystecomy.
10 days later: suffers left sided chest pain, SOB, coughed up blood with sputum
most likely to be:
pulmonary embolism
13 y/o underweight female.
Haemglobin 80 (115-165) MCV 110 (80-96)
strictly vegan. not yet started her periods.
most appropriate treatment?
Hydroxocobalamin (vit b12) and folic acid
notes: Microcytic anaemia (low MCV indicating small RBCs) Normocytic anaemia (normal MCV indicating normal sized RBCs) Macrocytic anaemia (large MCV indicating large RBCs)
large MCV –> macrocytic anaemia
- -> 1. megaloblast
- -> 2. non-megaloblast
- megaloblast
- —-> B12 deficiency (e.g. pernicious)
- —-> folate (e.g. diet) - non-megaloblast
- —-> alcohol
- —-> reticulocytosis
- —-> liver disease
- —-> hypothyroidism
What score is used to predict in hospital and 6 month mortality for MI?
GRACE score
72 y/o male
pc: back pain , being investigated for multiple myeloma
most specific biochemical investigation for multiple myeloma?
bence jones protein
Post mi you start people on aspirin and ticagrelor what are they at risk of?
- haemorrhage
- peptic ulcer disease common with aspirin because prostaglandin E2 formation inhibited via cox and it is ulcer protective
myeloma is cancer of which cell type
- plasma cells
- plasma cells are type of B lymphocyte that produce antibodies
four key features of myeloma
CRAB
C- calcium elevated
R- renal failure
A - anaemia (from replacement of bone marrow, normocytic)
B- bone lesions
Perform initial investigations:
FBC (low white blood cell count in myeloma) Calcium (raised in myeloma) ESR (raised in myeloma) Plasma viscosity (raised in myeloma) If any of these are positive or myeloma is still suspected do an urgent serum protein electrophoresis and a urine Bence-Jones protein test.
B – Bence–Jones protein (request urine electrophoresis)
L – Serum‑free Light‑chain assay
I – Serum Immunoglobulins
P – Serum Protein electrophoresis
Bone marrow biopsy is necessary to confirm the diagnosis of myeloma and get more information on the disease.
x-ray signs of myeloma
- punched out lesions
- lytic lesions
- raindrop skull
an elderly female
pc: sores at corners of mouth, pale, tongue swollen and smooth looking. nails are thin with upturned edges.
on pain medication for Osteoarthritis for many years.
name the clinical signs this patient is presenting with.
microcytic anaemia - caused by iron deficiency
angular chelitis : can indicate iron deficiency
koilonychia: spoon shaped nails, indicating iron deficiency
atrophic glossitis: smooth tongue due to atrophy of papillae and can indicate iron deficiency
72 y/o male post R hip replacement under spinal anaesthesia.
12 hrs later he is restless and confused. apyrexial.
OE: suprapubic mass dull to percussion
appropriate next step in management
urinary bladder catheterisation
70 y/o female
pc: LHS abdo pain.
pmh: has suffered with diarrhoea and constipation over past 5 years
OE: tenderness and guarding in LIF
USS: abscess in left paracolic gutter
most likely diagnosis?
diverticular disease
43 y/o female
pc: high temperature, right upper quadrant abdo pain, radiating to right shoulder tip, vomiting for 3 days. 2nd episode in a month.
likely to be?
cholecystitis
remember: charcots triad is for ascending cholangitis - RUQ pain - fever - jaundice
57 y/o increasingly severe abdo pain.
pain relieved by leaning forward. not by milk or food. she has a long history of alcohol intake.
likely to be:
chronic pancreatitis
IGETSMASHED
amylase
management:
- IV Resus, ABCDE
- IV fluids
- nbm
- Analgesia
causes
- gallstones
- alcohol
- post ERCP
23 y/o female
pc: ED, 8 weeks pregnant, previous pregnancy was uncomplicated.
had vaginal bleed last night post intercourse.
concerned she might be ‘losing the baby’
apart from miscarriage what is another differential:
cervical ectropion
do transvaginal USS to confirm
Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix)
The transformation zone is the border between the columnar epithelium of the endocervix (the canal), and the stratified squamous epithelium of the ectocervix (the outer area of the cervix visible on speculum examination).
50 y/o male
pc: 3 month hx intermittent painful diarrhoea mixed with fresh blood.
OE: obs are stable, abdo soft and non-tender. no masses.
DRE: normal
differentials ?
Colonic cancer
diverticular disease
Inflammatory bowel disease (ulcerative colitis)
infective cause unlikely with a 3 month history before presentation
52 y/o female
pc: ED w/ 12hr hx Upper abdo pain. vomitted several times, managing to drink sips of water only.
OE: alert, apyrexial. tenderness in RUQ, worse on deep breath. no guarding no masses. bowel sounds present.
indicate of:
give some differentials:
acute cholecystitis
murphys sign!
differentials
- peptic ulcer disease
- acute pancreatitis
you would expect jaundice with acute cholangitis and acute hepatitis
50 y/o male
pc: 30 min hx sudden onset severe central chest pain radiating to left arm and up neck.
OE: sweating, slightly breathless, anxious.
MI suspected.
name some other differentials?
- pulmonary embolism
- pericarditis
- aortic dissection
- oesophageal rupture / reflux
- pneumothorax
- myocarditis
gold standard treatment for STEMI ?
percuatneous coronary intervention
myocardial infarction complications
DARTH VADER
Death Arrhytmia Rupture Tamponade Heart failure
Valve disease Aneurysm Dressler syndrome Embolism Recurrence, regurgitation
signs of lower motor neuron disease?
Decreased tone
Weakness
Absent or reduced reflexes
Absent or Flexor plantar responses
Fasciculation
What is the most useful investigation to make a diagnosis of cauda equina?
MRI lumbar and sacral spine
32 y/o female , 33 weeks pregnant
G7P6
pc: unprovoked vaginal bleeds. blood soaked her trousers.
2 possible causes of heavy bleed
- placental praevia
- placenta totally or partially cover mothers cervix, can cause bleeding - placental abruption
you suspect cholecystitis in a patient:
Name 3 initial blood tests or investigations you would like to perform to help make a diagnosis?
- FBC - WCC elevated? infection
- CRP - infection
- LFTs - signs of liver disease
A 55 years old man, diagnosed with type 2 diabetes attends the Practice Nurse for an annual diabetic review.
Which test below is routinely requested for annual diabetic review?
Microalbumine urine test
79 y/o female
pc: 6 month hx increasing breathlessness on exertion.
72bpm irregularly irregular pulse, BP 118/72. she has a diastolic murmur.
likely cause of murmur?
atrial fibrillation
mitral stenosis likely cause
- obstruction of blood flow from LA to LV, LA pressure increases, heart enlarges and AF can occur
most common organism causing infective exacerbations of COPD is:
haemophillus influenzae
The combination of a peri-orbital and nasolabial scaly rash associated dandruff is a classical history for …
seborrhoeic dermatitis
most appropriate treatment lesions on face and trunk - topical ketoconazole
A 35 year-old lady presents to general practice with cyclical pelvic pain associated with dysmenorrhoea and dyspareunia.
On examination she has a fixed, retroverted uterus.
which investigation is most diagnostic?
- laparoscopy
A 38-year-old woman with a 4.5cm fibroid has been listed for a myomectomy following a 5 month history of heavy menstrual bleeding.
which drug should be prescribed to be taken whilst awaiting surgery?
gonadotrophin releasing hormone analogue
for patients with uterine fibroids:
- GnRH agonists may reduce the size of fibroid
- useful for short-term treatment
A woman who is 20 weeks pregnant presents for review. She informs you that she has had a previous baby who has developed a Group B streptococcus infection shortly following delivery.
what additional treatment will mother require?
- maternal intravenous antibiotic prophylaxis
- intrapartum antiobiotics
first line treatment for primary dysmenorrhoea?
NSAIDS
e.g. mefenamic acid is first line treatment for primary dysmenorrhoea
what is given to patients with heavy menstrual bleeding?
tranexamic acid
describe charcots triad
- ruq pain
- fever
- jaundice
ascending cholangitis
caused by bacterial infection of the biliary tree as a result of biliary stasis from obstruction.
treatment of ascending cholangitis involves?
- resuscitation
- IV antibiotics
- biliary drainage
what is given to prevent vasopasm in aneurysmal subarachnoid haemorrhage?
nimodipine
- calcium channel blocker
there is a high incidence of what bacterium in patients who have had pneumonia following influenza?
staph aureus
bnf advises co-prescription of flucloxacillin to the standard amoxicillin
3 y/o diagnosed with whooping cough.
most appropriate antibiotic therapy?
macrolide
e.g.
If admission is not needed, prescribe an antibiotic if the onset of cough is within the previous 21 days. A macrolide antibiotic is recommended first-line:
- Prescribe clarithromycin for infants less than 1 month of age.
- Prescribe azithromycin or clarithromycin for children aged 1 month or older, and non-pregnant adults.
- Prescribe erythromycin for pregnant women.
12 day old infant presents with right sided inguinal hernia. soft and easily reduced.
what is most appropriate management and why?
- surgery
- high incidence of strangulation
THIS is an aromatase inhibitor that reduces peripheral oestrogen synthesis. This is important as aromatisation accounts for the majority of oestrogen production in post-menopausal women
Anastrozole
- used for ER (oestrogen receptor postitive) breast cancer
anastrozole
- aromatase inhibitor
- reduces peripheral oestrogen synthesis
- aromatisation accounts for majority of oxygen production in post menopausal women
name 7 features of Wernicke’s encephalopathy?
CAN OPEN
C-confusion A-ataxia N-nystagmus O-opthamoplegia PE- peripheral N-europathy
After the six doses of atropine the patient is still showing adverse signs (his syncope) of the bradycardia so what would you do next?
- external pacing next indicated treatment
- long term would be pacemaker
what calcium picture often occurs in pancreatitis?
HYPOCALCAEMIA
- saponification of fats
- lipase leaks out of damanged pancreas
- fat –> triglycerides and fatty acid
- fatty acids combine with calcium to produce soap
- thus serum calcium can be used as a surrogate marker for level of enzymatic damage in pancreas
what disease is a common cause of nephrotic syndrome (proteinuria, oedema, hypoalbuminaemia) in children, with a peak age of 2-3 years old.
minimal change disease
- kidney disease
- large amounts protein lost in urine
what condition presents with the following triad
- purpuric rash
- joint pain
- abdominal pain
Henoch-Schönlein purpura
often renal involvement
causing haematuria
which condition classically presents as visible haematuria following a recent URTI?
IgA nephropathy / Berger’s disease
- IgA depositis in nephron causing nephritis
- glomerulae mesangial proliferation
management
= supportive, immunosuppresants to slow progression of disease
31 y/o female
pc: breast lump.
oe: non tender, hard, discrete lump on her left breast
lmp: 3 weeks ago
most appropriate management?
Suspected cancer pathway referral to a specialist breast clinic
Refer women aged >30 with an unexplained breast lump using a suspected cancer pathway referral
The only contraceptive that has a proven association with weight gain is:
depo-provera
78 y/o male
recovering from partial thyroidectomy to remove thyroid nodule 48hrs previously.
complains of muscle cramps and a tingling sensation around his mouth.
given the likely cause of his symptoms, what might be seen on ECG?
HYPOCALCAEMIA
- presence of muscle cramps
- perioral parasthesia
thyroid surgery can result in hypocalcemia
- direct dmanage of parathyroid glands —-> hyperparathyroidism
ECG finding: prolonged QT interval
symptoms of hypercalcaemia:
renal stones, painful bones, abdominal groans and psychiatric moans
- renal stones
- painful bones
- constipation, nausea and vomiting
- fatigue, depression and psychosis
Prolonged PR interval is associated with what chemical imbalance
hypermagnesemia
short ST segment is associated with what chemical imbalance
hypercalcaemia
tall peaked T waves are often associated with what chemical imbalance
hyperkalaemia
23 y/o male
pc: sore knee
hpc: has associated pain on urination and itchy, sore eyes.
indicative of:
what would the best treatment be?
acute reactive arthritis
- can’t see, can’t pee, can’t climb/bend the knee’
tx
- ibuprofen
if acute becomes chronic
- methotrexate and sulfasalazine
try and avoid high dose oral steroids
30 y/o female 10 weeks pregnancy
pc: 2episodes foul smelling red vaginal discharge
associated lower back pain, temperature of 39 degrees.
Blood pressure is 85/65 mmHg. A transvaginal ultrasound confirms an inevitable miscarriage.
most appropriate management?
surgical management
- evidence of infection
Total parenteral nutrition should be administered via a…
central line
A 32-year-old woman has come into your GP surgery requesting contraception. She is paralysed from the waist down from birth, but apart from that she has no other medical history of note and is fit and well with no symptoms.
which contraceptive is contraindicated due to her paralysis?
combined oral contraceptive pill
A 72-year-old gentleman is admitted to the emergency department with abdominal pain, nausea, fatigue, and confusion. He has a past medical history of stage IV lung cancer, diagnosed two months ago. Blood samples are taken and sent to the lab.
Given the most likely electrolyte abnormality, what would you most likely observe on this patient’s ECG?
HYPERCALCAEMIA
shortening of the QT interval
prominent U waves on ECG are associated with:
hypokalaemia
44 y/o female
pc: annual asthma review, symptoms very well controlled. has not had to use salbutamol inhaler.
dx: salbutamol, and inhaled beclomethasone steroid twice daily
next appropriate step in management.
step down treatment.
reduce dose of steroids 50%.
what is the preferred surgical management for intertrochanteric (extracapsular) proximal femoral fracture?
Dynamic Hip screw
Intramedullary nail is typically used for other extracapsular hip fracture types (reverse oblique, transverse, or subtrochanteric type) and femoral shaft fracture.
42 y/o male
pc: facial pain, pain worse on leaning forward
hpc: nasal discharge and a tickly cough
likely diagnosis?
sinusitis
- facial pain worse on leaning forward
acute treatment
- intranasal decongestants
what treatment option can be given to prevent further episodes of sinusitis?
intranasal corticosteroids
If C. difficile does not respond to first line metronidazole, what should be given next?
oral vancomycin
A 72-year-old man who has a history of asthma presents to the emergency department due to mild chest discomfort.
He has a chest x-ray that shows a small pneumothorax, around 0.8cm in size. The man is clinically stable.
What is the most appropriate management plan for this man’s pneumothorax?
Spontaneous pneumothorax
- primary: rupture of subpleural bleb
- secondary: underlying lung/pleural disease
patient has pmh of asthma —> secondary pneumothorax
ADMIT AND OBSERVE
In a small pneumothorax, <1cm, that is not causing severe shortness of breath the management is with admission, oxygen, and reassessment in 24 hours. If the pneumothorax was 1-2cm aspiration should be attempted, and >2cm, a chest drain should be inserted.
recommendations in primary pneumothorax?
IF rim of air <2cm and patient not sob then —-> discharge
otherwise —-> aspiriation
Visual hallucinations with dementia known as:
Lewy body dementia
A 58-year-old woman presents to the emergency department with confusion. She is found to have a raised temperature, tachycardia and is hypotensive.
she is presenting with a:
thyrotoxic storm
- confusion
- tachycardia
- hypotension
first line treatment for patient suffering thyrotoxic storm?
- beta blockers (symptom control)
- propylthiouracil (inhibits production of thyroid hormones)
- hydrocortisone (to prevent adrenal insufficiency due to hyperthyroidism)
the following signs indicate:
- tracheal deviation away from the side of the pneumothorax
- reduced air entry on the affected side
- increased resonance to percussion on the affected side
- tachycardia
- hypotension
tension pneumothorax
- caused by trauma to chest wall
- creases a one way valve
- lets air into but not out of pleural space
management of tension pneumothorax
Insert a large bore cannula into the second intercostal space in the midclavicular line.”
HBsAg shows:
surface antigen
shows current infection with HBV
What is HIV: Pneumocystis jiroveci pneumonia?
PCP is the most common opportunistic infection in AIDS
all patients with a CD4 count < 200/mm³ should receive PCP prophylaxis
e.g. co-trimoxazole
all men with erectile dysfunction should have which test done?
- testosterone
A second drug should be added in type 2 diabetes mellitus if the HbA1c
> 58 mmol/mol
Patient >= 60 years old with new iron-deficiency anaemia
next appropriate step?
- symptoms suggestive of anaemia
- blood tests: microcytic anaemia
- urgent colorectal cancer pathway referral
A 57-year-old male complains of painless abdominal distension over the past 2 months. He has a history of liver cirrhosis secondary to alcohol excess. He is otherwise well. Serum albumin ascites gradient (SAAG) is 15 (normal <11).
treatment of choice:
high SAAG –> non-peritoneal cause of ascites
- cirrhosis
- budd-chiari syndrome
- nephrotic syndrome
low SAAG —> peritoneal causes of ascites
- tuberculosis peritonitis
- peritoneal mesothelioma
SPIRONOLACTONE
- to counter the deranged RAAS
rapid correction of hyponaetraemia may lead to:
central pontine demyelination
9 month old babt boy
pc: 2 day hx fever & dry cough.
pmh: born 2 weeks premature
OE: 38.6, hr 110bpm, RR, 45 breaths per minute. tachypnoea, wheeze on auscultation and nasal flaring.
what condition is likely?
BRONCHIOLITIS
- child premature
- low grade fever
- wheeze on auscultation
Management
- supportive measures such as maintaining oxygenation and hydration
A 45-year-old gentleman with a background of hypertension, psoriasis and bipolar disease presents to his GP with a thick scaly plaque on his right knee after starting a new medication.
like diagnosis?
Psoariasis
- lithium can be a trigger
methotrexate is used as treatment for severe psoriasis
